Considering knee replacement? Answers from a local doctor

Nearly 1.3 million Americans get knee or hip replacements every year. Specifically, some 790,000 total knee replacements and 544,000 hip replacements, according to the American College of Rheumatology. And that number is growing as our population ages.

Lots of people – of all ages – are candidates for this surgery. So, when Dr. Harold “Del” Schutte, Jr., an orthopedic surgeon, hosted a recent Q&A session for people considering the procedure, it drew an inquisitive crowd of more than 50.

There’s no one in the region better qualified than Schutte to address this topic. He founded the Charleston Institute of Advanced Orthopedics and the East Cooper Medical Center comprehensive joint reconstruction program, of which he’s the director.

Schutte told the group, “Joint replacements are life-changing procedures. If you look at all surgical procedures in terms of quality of life gained per healthcare dollar spent, hip replacements are No. 1, knee replacements are No. 2 and cataracts are No. 3. It’s as close to 100% as you can get.”

The session lasted for more than an hour; the following has been edited for length and clarity.

What causes joint pain?

A number of things – arthritis, injuries, overuse, autoimmune diseases, age-related wear and tear.

What are the most important things to know about joint replacement?

Most – about 70% – are done on an outpatient basis. Patients go home the same day.

Not everyone who contemplates joint replacement will need it. Just because you come see us doesn’t mean you’re automatically getting a joint replacement. There are many things we can try first – injections, physical therapy, braces. It’s important to remember: Surgeons don’t automatically recommend surgery every time they see a patient who’s hurting.

But if conservative treatments don’t work, the good news is: We do several hundred knee and hip replacements a year. They take, on average, only about 45 minutes. They’re very common procedures for us. But it’s likely the only one you’ll ever have, and we take that seriously.

These surgeries are elective, and the most important question to ask when considering it is: Am I less active because of the pain?

Our goal is to keep you active. You don’t want to gradually dwindle down from 10,000 steps a day to 9,000, then 8,000 and so on. That has all kinds of consequences. You should be way more active after a hip or knee replacement than you were before.

Most patients are walking within an hour or two of surgery.

You can think of a joint replacement as you would think of replacing the tires on your car. We’re replacing the wheel and the tire. We’re not altering the motor, which you can think of as your muscles. Your muscle strength is up to you. You don’t want to let them get too weak before surgery, or you won’t have the best result. In the most extreme cases, muscle weakness may be irreversible.

What do you need to do to prepare for knee surgery?

Yes. It’s not an instant fix. Patients should regard the entire thing – pre-op, surgery and post-op as a partnership they enter into with their surgeon. The more optimal your health before surgery, the better result you can expect.

Our office works with patients on thorough screenings of all medical risk factors, and we make sure we get your dental and cardiac clearances, if needed. (See sidebar.)

For patients on weight-loss medicines like Ozempic, the precautions are different. They have to stop those medications before surgery. People on blood thinners, such as Eliquis, need to take the same precaution.

You might be asked to lose weight before surgery. It pays to be at, or close to, your ideal weight. For every pound you lose, it's 4 pounds less stress off your hip or knee. It’s that dramatic.

Patients with arthritis sometimes say they can’t lose weight. But it is possible, and it makes a huge difference. The weaker your muscle, the more important it is for you to be at a lower weight.

What is recovery from knee replacement surgery like?

Most people are driving within the first or second week after surgery, but full recovery takes about six weeks. Our biggest fear is people overdoing it. There’s a big emphasis on taking it easy, letting the swelling go down.

People who are very physically active always ask how soon they can return to the sport they love. For golfers, you can putt on day one, chip on week four and take a full swing at week six.

Everybody wants to return to their normal activities quickly. But you don’t want to go through this again 10 or 15 years down the road. And there’s no reason you should have to, as long as you follow the guidelines. We’re aiming not just for short-term high performance, but for long-term results.

I’ve had patients get a new knee and walk 10 miles – which they’d never done – and then complain that their knee hurts. That has nothing to do with their new knee; those are the muscles doing the same thing they’d be doing if you hadn't had a knee replacement.

In many cases, there are no post-op precautions. But let common sense prevail. If you’re too aggressive too soon, it can lead to problems.

In your experience, does one sex fare better than the other during recovery from knee replacement surgery?

Not at all. Most studies show that women tend to fare better. Seriously, the hardest candidate may be a middle-aged, muscular man. They often have lower pain tolerance and may be less likely to follow directions.

You mentioned conservative treatments for knee pain. Are injections part of that?

Yes. Cortisone injections are the most effective. Studies haven’t shown gel injections or hyaluronic acid to be any better than a placebo. Still, some people have great results with those, and we have no problem injecting them.

The shots do stop working after a while, though. The first one might work for six months to a year. The next ones work a little less.

Does your office use robotic surgery?

Yes. In fact, I performed the state's first robotically assisted total knee replacement. I also pioneered tourniquet-less knee replacement in our trademarked “Free the Knee” program for rapid recovery. Now, almost everybody has some form of guided navigation or robotic system. But we have a tremendous experience using the robot.

I want to be clear that it’s not the robotic arm performing surgery. It’s the surgeon’s hands on the drill. Think about getting your tires realigned. The mechanic could do it by sight and make a good guess – or hook it up to a computer and get exact measurements. Which would you want?

With robotic surgery, is there a smaller incision?

No. It’s the same size. A few years back, there was a trend toward minimally invasive knee replacements. There were some doctors who made incisions so small that they were forced to put the implant in crooked. Those had to be revised.

How has joint replacement surgery improved over the years?

Implants used to last only 10 or 15 years. We’d tell patients to wait until they were 75 or 80 to have it done so that they didn’t have to have the replacement replaced. There were two problems with that. One, people limp around and the muscle wastes away. By the time you replace the joint, the muscle’s gone – and you still have a permanent limp.

The second problem: If you live to be 70, you have a 50% chance of living to be 100. And if you live that long, you might need a second surgery.

Today, if you need surgery, you gain nothing by waiting. It used to make sense to wait until your 50s. Now, we have patients in their 20s, 30s and 40s, because the new joints last so long.

I should add that newer, muscle-sparing techniques in hip and knee replacements have led to quicker recoveries.

I’ve needed a knee replacement for decades, and now my quadriceps have gone to nothing. Do you recommend building up your quads prior to surgery?

Yes, as much as possible. But with this caveat: You need to safeguard your knees. When you try to build up your quads, you’re usually moving your knees. Wall squats, where you sit against the wall for support with your knees not moving may be preferable.

Five months ago, I tore my Achilles playing pickleball. It wasn’t painful, surprisingly – but it did lead to four months of limping. Going up steps, one at a time, meant I was wearing out my other knee cap.

That’s why we encourage people not to wait. The muscle can waste away in as little as six or eight months. Once that happens, it’s really hard to rebuild.

What about partial joint replacements? Would you rather have a total than a partial?

Absolutely. We have to revise partials to totals quite frequently.

Most people prefer one procedure that doesn’t need to be revisited. If you have a partial, your surgeon needs to follow you closely. If it fails, it could create a defect that forces you to use a revision prosthesis. (That’s a surgical procedure that replaces a previously implanted artificial joint – or prosthesis – with a new one. Revision surgery may be necessary due to wear and tear, failure or complications from surgery.)

But partials are an important part of knee care. Most people prefer having a procedure that doesn’t need to be revisited. But in certain cases and for certain people, a partial may be a reasonable choice.

Do you use PRPs in your practice?

We do. You’re referring to platelet-rich plasma – a treatment that injects a patient’s own platelets – which contain growth factors – into a damaged area to reduce pain and accelerate healing. PRP is good for tendon injuries such as tendinitis and myositis, but it’s not effective for arthritis.

I need a knee replacement, but I'm planning a ski trip soon. What’s the right timing?

People often ask about timing their surgery so it doesn’t impact a vacation. I would wait until three months after the ski trip to have surgery.

I tell patients: If you give me six to eight weeks before your summer vacation, the odds are you’ll be better than you were before in time for your trip.

Typically, hips recover a little quicker than knees. With knee replacements, patients see about 80% improvement in the first six weeks. That reaches 90% during the first six months. The last 10% can take up to a year.

What sets your practice apart from others?

First, we’re a high-volume, concierge-style practice. We do a large number of hip and knee replacements each year, but we’re not like a factory. We work to understand what makes each person unique as a candidate for surgery. Each person has different demands and different genetics. We tailor pre- and post-op recommendations to each specific patient.

Secondly, we’re a high-tech practice, but we’re also high touch.

Our team may be our biggest differentiating factor. We’ve worked together for a long time. Nurse practitioner Amy King, who’s a certified gerontological clinical nurse specialist, has been with me more than 20 years. Dr. Dustin Hambright, another orthopedic surgeon; Terri Blackwell, physician assistant; Sarah Voges, nurse practitioner; Savannah Steevens, a registered nurse; and Erika Romfo, our supervisor and surgery scheduler have all worked at the clinic for years. We started the hip and knee program at East Cooper Medical Center 12 years ago. The fact we’ve worked together for so long increases our success rate.

We have a great partner in Novant Health. They give us enough staff to be really attentive and provide us with the latest high-tech instruments and machines.

Lastly, we like to see and monitor post-op patients frequently – to the point of hovering. We call you the day after surgery. We see you a week post-op and again in two weeks, if necessary. We’ll fine-tune our recommendations if recovery is progressing faster or slower than we expected. We want to set you up for success.